This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Monday, 16 February 2009

Taking report on too many patients PART 2

I am having a really tough time articulating this for people who are not nurses. I will try anyway because it is so important. If have ever wandered onto a ward expecting the first person you see in uniform to have the information you want, and then threw a tantrum about the "stupid nurses" you should read this. If you have ever become upset because a nurse responded with "that's not my patient" you should read this. You need a reality check.

I have had a few emails off of nurses about report and handovers. The American nurses are telling me that they arrive to work and take report on 4-12 patients on their 30 bed acute wards. That report alone takes 45 minutes due to the sheer volume of information one needs to know to be a primary nurse for those patients. Then there are the constant interruptions throughout handover. The idea of taking report on the whole ward and staying on top of everything for all of those people is generally understood (by those of us who do this everyday) to be "ludicrous". First of all it would take hours. You cannot be away from those patients for hours receiving handover.

However, the idea of getting involved with the patients that you haven't had handover on is understood to be dangerous. It is impossible to keep up with your own assignment let alone get involved with the other one. What if my patient gets labs drawn late, IV med late, or I miss a change in condition because I went to research a patient on my colleagues assignment so that I could answer a relative's question? I have harmed my patient if I do that. I want to help the family but it may take ages to hunt down that patients nurse and it will take ages to make my way to the notes and research and investigate the answers to their questions. it's doubtful that anyone has had the time to document everything anyway. I am constantly interrupted during the day, constantly with these queries.

It is a nice idea to think that all nurses on the ward during a shift have up to date knowledge about all the patients. But in practice it doesn't work at all. Yet having report only on one side of patients and not being aware of the situation with the other nurses patients is also a massive problem. This is what I am trying to reconcile.

If nurses decide to constantly try and update eachother about their patients so that everyone knows what is happening we end up with nothing but big fuck ups. First of all, any time spent away from patients trying to handover is dangerous. Who the heck is doing the work and watching the patient with a trained eye if we are constantly updating eachother? The teenage cadets? You would not believe the sheer volumes of information we are trying to keep track of and you would not believe how quickly things change and how unorganised it all is these days in acute care. You also wouldn't believe how easily a patient could be killed either because the nurses are constantly trying to handover to eachother, or because they weren't.

Nurses are of course encouraged to help out their colleagues and their colleagues patients when the need arises. But taking something on with a patient outside of your assignment when you do not have up to date info on them is a minefield. If another nurse's patients asks for something so simple like a glass of water or a pain med and you supply it without being updated you could seriously harm someone. It's more complex than this, but I am trying to keep it simple for the sake of clarity.

Our acute medical wards started moving from 4 nurses to 2. This what at a time when the patients were becoming more complicated, the work loads were tripling, and everything just started moving faster. Things will continue in this upwards spiral due to modern changes in healthcare.

We realised at this point that 2 nurses taking handover at the beginning of their shift on 35 patients was taking too long. We started work at 7:30 AM. The night nurse comes off the ward at 7:30 AM and starts giving us report on each patient: Name age, doctor, diagnosis, history, tests, assesments, treatments, social , physio, meds, problems, old issues, new issues etc etc. It was 9:00 before report ended and we hadn't even set eyes on the patient yet. You need a heads up on so much information your brain hurts when it is all over and you can barely process what you heard. It's likely that I haven't met any of these patients before.

Not only that but the care assistants would constantly be in and out during handover to tell us that someone had fallen, someone couldn't breathe, this patient needed morphine, another has just vomited a litre of blood. You can't leave that until the end of report. You also cannot touch a patient until you have had report. The phone rings constantly during report. No ward clerk present thanks to cutbacks.

The first thing all the relatives do when they wake up in the morning is ring to ward to find out what kind of night mother had and ask what time the docs are coming. Be damned if we nurses know when the consultants are going to grace us with their presence. If the night nurse is on the phone constantly answering questions we are not getting handover. We are sat there getting pissed off because we haven't started our shift yet. We (the day nurses) can't head out onto the ward and start anything if we don't actually know anything about the patients.

We do not learn what we need to know about them by osmosis or psychic ability. We are not there everyday and when you come back in after a day off everything has changed. We need time to learn about the patients' issues. That's why we have handover. This is not an issue in nursing homes and subacute units. They have the same patients there day after day and only need a quick handover to update.

I have often come in after 3 days off to find that I am the primary nurse for 15 + patients I have never laid eyes on before. And we can't even get through report or have a quick look at the notes before we start our shifts due to constant interruptions primarily in the form of phone calls from relatives. Jesus try keeping all the names straight in that situation let alone everything else. Just try it or shut the fuck up.

We know that you can't have the day nurses sat in a room for 2 hours at the beginning of their shift trying to get handover. The night nurses stopped being paid from 0800 onwards so they were there unpaid until 0900 or even 1000 trying to give us report. What is the solution to this? We no longer have a charge nurse/sister/matron there 5 days a week who knows the patients like the back of her hand. If we do have sister on duty, she is there instead of a staff nurse. That means she has to be a primary nurse doing care and cannot fart about with the doctors all day staying updated on patients. We tried taping report. That failed due to constant interruptions.

So our solution was this: There are 2 nurses for a 35 bed ward. Instead of both of us trying to listen to report on all those patients we will EACH TAKE A SIDE. Night Nurse Kate can handover patients in bed 1-18 to me. Night Nurse Beth can take the other day nurse aside and handover beds 19-35 to her. Then we are usually out of handover at 8:15. Then I can go and actually set eyes on my patients a lot earlier and get started. All 35 of them are due meds that have to be given on time before 0900. Otherwise they are written up as errors. We need to get started.

This is why nurses each have a "side" rather than updated info on all patients.

Are you guys following me so far? I hope so. This is really important even if you are bored.

I'm not done with this subject yet. The ranting and swearing is going to come in part 3.

20 comments:

Thank you so much for trying to get to the heart of the matter. As a frequent in patient with multiple co-morbidities you can imagine that I too have some insight into the pressures that you refer to. I am often on the receiving end of clinical decisions not being communicated effectively.

In my experience this does not just happen on the ward (acute or otherwise) but also between wards (e.g. High dependancy or Post Op Surgical Units) and the acute ward the patient is later transferred to. It also - damn it - happens between one clinic and another and between all clinics and the general practice whenever any change is made to polypharmacy - with potential for systemic failure if not criminal negligence.

This is my reality - as a patient! I do not blame "nurses" or "doctors" or "paramedics" or "GPs". I realise that most are well meaning even if some are a little confused. I understand also that there will be a (hopefully normal) distribution of skills and "competencies". From time to time however I do experience the plain stupid as well. Generally though the clinicians do as well as can be expected with current staffing levels and the need to demonstrate adherance to protocols.

Throughout the health care system in the Northern city that I inhabit we do seem to have excellent clinicians albeit they work under resource and managerial inadequacies.

If they were to compete in the Olympics however the relay teams that they would form would forever be dropping the baton!

The misinformed management (of both patients and the service as a whole)might start on the ward during the handover but it is by no means limited to that situation. It pervades the current NHS which, while it may be able to demonstrate eficiencies, struggles to demonstrate - let alone achieve - effectiveness.

Too many of the reforms over the past 20 years have pandered to an excess of faith in the mechanisms of the market place in a vain attempt to depoliticise the setting of local priorities based on bottlenecks in local systems.

I expect it will take a few more years before the shake out in financial markets sees altruism replacing fear and greed as motivators of behaviour in public services. The managerial bully boys will hang on a little longer in the UK public sector I'm afraid - but a fall from grace will also come to them in time.

In the meantime with an ageing population requiring more complex yet safe care for multiple co-morbidities the importance of collaborative clinical records and handover reporting will be more important not less.

The ward handover stupidity you are describing is symptomatic of more general problems caused by understaffing, exacerbated by current vogue for a storm trooper style of local management, and sadly soothed by the apparant indifference of patients and carers. However "this too will pass".

In the meantime please do not think all "patients" are incapable of empathy and of understanding the plight you are describing. Some feel as strongly as you do and I for one wish all power to your literary elbow in - describing the situation from your viewpoint - and look forward to part 3.

When working on the wards I knew every patient there, if I told a relative "that is not my patient" sister would have been on me like a ton of bricks. On night duty I had to give an accurate ward report to the night sister and to the night nursing officer - no excuses, I could make it up but I had to be confident. I knew what each patients preferences were, I knew what drugs they were on and what tests they were going to be getting. BUT, and it is a huge but, I worked a 5 day week, there were a few more staff available and patients were in hospital longer. I could go on annual leave and know that half the patients would still be there when I came back with nothing changed. As an example, in the acute medical ward I worked on patients who were post MI were in bed for a minimum of 3 days (this was after their time in CCU) then they were only allowed up once a day then crossing to toilet. they were in the ward for at least 10 days. A much more calm and civilised way of working - also wrong and as has been proven extremely bad practice. So continue to complain and don't let old farts like me tell you "it was better in the old days". It was, but for much more complex reasons than that we were better nurses than those of today (we were not).

I agree with you Grumpy. Who was looking after your patients while you were giving these handovers and who was fielding questions from families, doctors, and requests from the patients during the handover? Were there other nurses on the ward?

I know I shouldn't say this but sister ruled the roost, The nurse in charge gave the handover to everyone - 20 minutes tops - there were always nurses on the ward, HCA's , other trained staff, students. Ward round were very regimented and done at the same time every week, different consultants did their round on different days. Busy 24 bedded acute medical ward would have only 2 HCA's, but would have 1 sister, 4-5 staff nurses 3-4 enrolled nurses, 3-5 student nurses and 2-3 pupil nurses. Students and pupils would be at different levels. Each shift would be minimum of 2 staff nurses, 1 enrolled nurse 2 students 1 pupil and 1 HCA, that's a minimum. That is why the old days were good, we had the resources - I should point out that I am talking about Scotland which has historically been better staffed than England. I put the blame squarely at the internal market which tries to do things as cheaply as possible and as Prisoner of Hope said it can be efficient but it is not effective.

My gosh I knew they were staffed better in the old days but not that well. CHRIST. How dare they come down on today's nurses!!!!

Our consultants never show up at the same time twice. We do not know when they are coming. But when they do come they snap their finger at the staff nurse and expect her to drop that syringe of pain meds she is about to give, and follow them around for an hour. This leaves no one to care for the patients. This happens 3 or 4 times between 8AM and 1PM.

...and then if I tell them to hang on a minute because I am just about to give a patient pain meds, or another doctor's patient is bleeding out..they start screaming and saying that we are holding them up and don't understand how to prioritize!! Fuckers.

I trained 50 years ago and I think the problems you have now started with the "market forces" brigade.Maybe they need to start the apprentice style training again, which gives a steady supply of student nurses actually on the wards. The student nurses were all grades from 1st year to third year, which gave us experience and assured that there were nurses (with a permanent sister and staff nurses in charge) at all times. The rapid turnover of patients does not help and leads to cases like the one reported recently where an elderly man was sent home alone and died the next day.Care assistants with little training maybe a false economy if the hospitals are then paying out for mistakes and poor hygiene.

Apprentice training will not give us extra staff. We often get student nurses on the wards doing placements. When we do, management sends our care assistants away "because we have a student". They got rid of bank and the float pool and use wards to staff eachother.

You can't just train nurses as apprentices anymore. Nursing school needs to be hands on as well as academic. Things of changed. The ward nurses have to do a lot of critical thinking. I had to take a lot of science and math and university and it helps me everyday on the ward.

If a student was simply trained as an apprentice without the academic side as well they would not be able to handle being the primary nurse for a group of patients in acute care upon graduation. They need knowledge behind there actions. It's not like we ever have doctors on the ward anyway. They need to be able to think and think fast.

Not understanding the science behind what you are doing is a good way to get your license pulled.

Apprentice style nursing was not all practical nursing! We too had to do study blocks and also had to "make critical decisions". I left school with the necessary qualifications for university, as did many of the girls I trained with, we just chose to train as nurses. There were two grades of nursing qualifications State Registered nurses (3years) and State Enrolled nurses (2 years). The latter concentrated on the practical aspects. I realise that many things have changed and there is far more technology used now, but I can assure you that we were not glorified care assistants.Many of my colleagues have had very responsible positions around the world.

Thank you. I work as an Administrator in a busy Nursing home,& it's important to me to protect the RNs from interruption during Handover & drug rounds. If a relative goes to hospital I shall ask when handover is and when is a good time to phone & will ascertain whether I am speaking to the correct nurse rather than just waylaying any nurse who is writing at the nurses' station, as I must confess I have in the past when my daughter has been on a ward. i have never minded waiting at all, because I know that although my query is important to me, it isn't urgent, but I know that I haven't always picked the right time.

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In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.